Christa Kruger

Dissociative identity disorder: An empirical overview:

Objective: Despite its long and auspicious place in the history of psychiatry, dissociative identity disorder (DID) has been associated with controversy. This paper aims to examine the empirical data related to DID and outline the contextual challenges to its scientific investigation. Methods: The overview is limited to DID-specific research in which one or more of the following conditions are met: (i) a sample of participants with DID was systematically investigated, (ii) psychometrically-sound measures were utilised, (iii) comparisons were made with other samples, (iv) DID was differentiated from other disorders, including other dissociative disorders, (v) extraneous variables were controlled or (vi) DID diagnosis was confirmed. Following an examination of challenges to research, data are organised around the validity and phenomenology of DID, its aetiology and epidemiology, the neurobiological and cognitive correlates of the disorder, and finally its treatment. Results: DID was found to be a complex yet valid disorder across a range of markers. It can be accurately discriminated from other disorders, especially when structured diagnostic interviews assess identity alterations and amnesia. DID is aetiologically associated with a complex combination of developmental and cultural factors, including severe childhood relational trauma. The prevalence of DID appears highest in emergency psychiatric settings and affects approximately 1% of the general population. Psychobiological studies are beginning to identify clear correlates of DID associated with diverse brain areas and cognitive functions. They are also providing an understanding of the potential metacognitive origins of amnesia. Phase-oriented empirically-guided treatments are emerging for DID. Conclusions: The empirical literature on DID is accumulating, although some areas remain under-investigated. Existing data show DID as a complex, valid and not uncommon disorder, associated with developmental and cultural variables, that is amenable to psychotherapeutic intervention.

Psychometric validation of the State Scale of Dissociation (SSD)

Although dissociative phenomena are often transient features of mental states, existing measures of dissociation are designed to measure enduring traits. A new present-state self-report measure, sensitive to changes in dissociative states, was therefore developed and psychometrically validated. Fifty-six items were formulated to measure state features, and sorted according to seven subscales: derealization, depersonalization, identity confusion, identity alteration, conversion, amnesia and hypermnesia. The State Scale of Dissociation (SSD) was administered with other psychiatric scales (DES, BDI, BAI, SCI-PANSS) to 130 participants with DSM-IV major depressive disorder schizophrenia, alcohol withdrawal, dissociative disorders and controls. In these sample populations, the SSD was demonstrated as a valid and reliable measure of changes in and the severity of dissociative states. Discriminant validity, content, concurrent, predictive, internal criterion-related, internal construct and convergent validities, and internal consistency and split-half reliability were confirmed statistically. Clinical observations of dissociative states, and their comorbidity with symptoms of depression and psychotic illness, were confirmed empirically. The SSD, an acceptable, valid and reliable scale measuring state features of dissociation at the time of completion, was obtained. This is a prerequisite for further investigation of correlations between changes in dissociative states and concurrent physiological parameters.

Separating fact from fiction : an empirical examination of six myths about dissociative identity disorder

AbstractDissociative identity disorder (DID) is a complex, posttraumatic, developmental disorder for which we now, after four decades of research, have an authoritative research base, but a number of misconceptualizations and myths about the disorder remain, compromising both patient care and research. This article examines the empirical literature pertaining to recurrently expressed beliefs regarding DID: (1) belief that DID is a fad, (2) belief that DID is primarily diagnosed in North America by DID experts who overdiagnose the disorder, (3) belief that DID is rare, (4) belief that DID is an iatrogenic, rather than trauma-based, disorder, (5) belief that DID is the same entity as borderline personality disorder, and (6) belief that DID treatment is harmful to patients. The absence of research to substantiate these beliefs, as well as the existence of a body of research that refutes them, confirms their mythical status. Clinicians who accept these myths as facts are unlikely to carefully assess for dissociation. Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve. The myths we have highlighted may also impede research about DID. The cost of ignorance about DID is high not only for individual patients but for the whole support system in which they reside. Empirically derived knowledge about DID has replaced outdated myths. Vigorous dissemination of the knowledge base about this complex disorder is warranted.

Institutional abuse and societal silence: An emerging global problem

Australian & New Zealand Journal of Psychiatry, 48(1) The Australian Royal Commission into Institutional Responses to Child Sexual Abuse was announced by Australian Prime Minister Julia Gillard on 11 January 2013. Examining how institutions with a responsibility for children ‘have managed and responded to allegations and instances of child sexual abuse and related matters’ (Australian Government, 2013) arguably represents the most wide-ranging attempt by any national government in history to examine the institutional processes (or lack thereof) for addressing such abuse. Its frames of reference are very wide: The Commissioners can look at any private, public or non-governmental organisation that is, or was in the past, involved with children, including government agencies, schools, sporting clubs, orphanages, foster care, and religious organisations. This includes where they consider an organisation caring for a child is responsible for the abuse or for not responding appropriately, regardless of where or when the abuse took place. (Australian Government, 2013) The phenomena of individuals, or groups of individuals, associated with institutions using their roles to further their sexual abuse of children or to assist in the cover-up of such practices will necessarily be illuminated by the Royal Commission. When the national inquiry was announced, there were no less than three state-based inquiries dealing with child abuse planned or underway in Australia, one in Queensland, one in Victoria, and a just-announced inquiry in New South Wales. It is a testament to the enduring and tenacious use of power by those associated with societal institutions that, in a global sense, it has really only been within the last two decades that the world has witnessed progressive revelations involving many instances of individuals or groups from such institutions sexually abusing children. This is notwithstanding a demonstrated palpable resistance on the part of the many institutions to cooperate in the uncovering of such crimes or the prosecution of those responsible. Research demonstrates that approximately two-thirds of both inpatients and outpatients in the mental health system report a history of childhood sexual and/or physical abuse (see Read et al., 2004 for an extensive review). If emotional abuse and neglect are added to the mix, the percentage reporting an adverse/traumatic childhood becomes even higher. The Adverse Childhood Experiences (ACE) Study, a pioneering United States epidemiological survey, has provided retrospective and prospective data from over 17,000 individuals regarding the effects of adverse events, including child abuse, during the first 18 years of life. This enormously significant ongoing study demonstrates the enduring, strongly proportionate, and frequently profound relationship between adverse childhood experiences and emotional states, disease burdens, high-risk sexual behaviour, self-destruction, drug abuse, health risks/healthcare costs and early death, even decades later (Felitti and Anda, 2010). Furthermore, a recent detailed review found that child sexual abuse is intimately related to increased risk for poly-victimization, social stigmatization and impaired attitudes towards the self and the social world (Olafson, 2011). A sizeable proportion of victims with childhood abuse experiences present to medical and psychiatric systems and receive various diagnoses which do not necessarily refer to the traumatic origin of their illness. While research on dementia, schizophrenia, bipolar disorder and depression is widely funded, grants are rarely given to study the mental health consequences of ongoing childhood trauma, which include dissociative disorders Institutional abuse and societal silence: An emerging global problem

Dissociative Mental States Are Canonically Associated with Decreased Temporal Theta Activity on Spectral Analysis of EEG

Quantitative electroencephalographic (QEEG) changes relating to dissociative experiences have only rarely been demonstrated, and dissociative states were not quantified in those studies. The aim of this study was to explore concurrent associations between quantified dissociative states and QEEG spectral parameters, in particular theta activity, in psychiatric patients. Fifty psychiatric patients completed the State Scale of Dissociation (SSD) immediately after a 15-min EEG recording. The EEG was assessed by conventional clinical visual analysis as well as by quantitative (QEEG) spectral analysis. Canonical analysis was performed between the set of SSD subscale scores and the following QEEG parameters: alpha–theta magnitude ratios, and relative as well as absolute theta magnitude obtained from right and left mid- to posterior-temporal and parieto-occipital derivations. The SSD transferred well to the present data in terms of reliability and internal criterion-related validity. The SSD and Dissociative Experiences Scale (DES) correlated significantly (r = .73, p < .001). Conventional EEG analysis identified 29 EEGs (58%) as abnormal. The main abnormality in 23 EEGs was slowing, maximal temporally in half of these cases. Canonical analyses confirmed a statistically significant relationship between the dissociation variables (especially conversion and depersonalization symptoms) and the QEEG variables (especially relative theta magnitude in the temporal regions; R = .72, p = .03, for SSD–QEEG; and R = .66, p = .04, for DES–QEEG). Quantified dissociative mental states are positively canonically associated with decreased temporal theta activity and increased alpha–theta ratios on QEEG in psychiatric patients with a high tendency to dissociate. The potential implications of the dissociation–theta–alpha relationship for understanding normal attentional processes need to be studied further.

Predicting a dissociative disorder from type of childhood maltreatment and abuser-abused relational tie

ABSTRACT We investigate the types of childhood maltreatment and abuser–abused relational ties that best predict a dissociative disorder (DD). Psychiatric inpatients (n = 116; mean age = 35; F:M = 1.28:1) completed measures of dissociation and trauma. Abuse type and abuser–abused relational ties were recorded in the Traumatic Experiences Questionnaire. Multidisciplinary team clinical diagnosis or administration of the SCID-D-R to high dissociators confirmed DD diagnoses. Logit models described the relationships between abuser–abused relational tie and the diagnostic grouping of patients, DD present (n = 16) or DD absent (n = 100). Fisher’s exact tests measured the relative contribution of specific abuse types. There was a positive relationship between abuse frequency and the presence of DD. DD patients experienced more abuse than patients without DDs. Two combinations of abuse type and relational tie predicted a DD: childhood emotional neglect by biological parents/siblings and later emotional abuse by intimate partners. These findings support the early childhood etiology of DDs and subsequent maladaptive cycles of adult abuse. Enquiries about childhood maltreatment should include a history of emotional neglect by biological parents/siblings. Adult emotional abuse by intimate partners should assist in screening for DDs.

The prevalence of metabolic syndrome and its associated factors in long-term patients in a specialist psychiatric hospital in South Africa

OBJECTIVE The aims of this study were to determine the prevalence of metabolic disorders in long-term psychiatric patients, and the relationship between known risk factors and these metabolic disorders. METHODS All psychiatric in-patients ≥18 years, who had been admitted ≥six months were invited to participate. Eighty-four patients participated. They were interviewed, examined, measured and blood tests conducted to determine several demographic and clinical variables including age, gender, weight, blood pressure and fasting blood glucose. RESULTS The prevalence of the metabolic disorders were: metabolic syndrome 32%, hypertension 32%, diabetes mellitus 8%, cholesterol dyslipidaemia 32%, triglyceride dyslipidaemia 29%, low density lipoprotein (LDL) dyslipidaemia 50%, overweight 37%, and obesity 24%. Black African and female patients were more likely to have metabolic syndrome. Female patients were more likely to have cholesterol dyslipidaemia and obesity. Hypertension was associated with age. Ninety-six percent of patients with dyslipidaemia were newly diagnosed during the study. Three out of the seven previously diagnosed diabetic patients had raised fasting blood glucose levels. CONCLUSION The prevalence of metabolic syndrome falls towards the lower limits of the expected prevalence rate. Race and gender showed a moderate statistical association with metabolic syndrome. There is a lack of screening for dyslipidaemia in this setting. Diabetic patients should be referred to specialist diabetic clinics for better monitoring and control.

Clinical factors associated with rape victims' ability to testify in court : a records-based study of final psychiatric recommendation to court

OBJECTIVE A rape victim may encounter professionals in both the health and the legal systems. Unanswered questions remain about clinical factors associated with a rape victims ability to testify in court, and the quality of care offered to rape victims. The objectives of this study were thus to determine the clinical factors that are associated with a rape victims ability to testify in court, as well as to undertake a preliminary exploration of the referral system between the court and the mental health services. METHOD A retrospective study was conducted of rape victims referred by the court (n=70) to be assessed psycho-legally by psychiatrists. Rape victims who were recommended as able and those recommended as unable to testify in court were compared with regard to their clinical characteristics. RESULTS Thirty-seven (53.6%) victims were recommended as able to testify and 32 (46.4%) victims as unable to testify in court. Victims from rural areas and victims with severe mental retardation were statistically significantly more often found to be unable to testify in court. Almost half (49.2%) of the victims were referred by court for first assessment within six months of being raped. Most (63.5%) victims were assessed for the first time within one month of being referred. CONCLUSION The decision about a victims ability to testify should not be based solely on the two statistically significant variables but, rather, individualised. Optimal mental health and legal services should be offered to rape victims. Further studies are required in assessing the collaboration between the health and legal systems.

Self-Injury: Symbolic Sacrifice/Self-Assertion Renders Clinicians Helpless

Potter’s paper starts by situating self-injury in a broader discourse of body modifications. In this discourse the body is being used as a text, a tool to communicate meaning. The meaning that is communicated might be difficult or impossible to articulate otherwise (by using words, for example). The meaning of the communication is embedded in a context of social, cultural, religious, political, and other norms. Potter explores possible interpretations of the meaning of self-injury in women with BPD, including an interpretation of self-injury as symbolic sacrifice. She suggests that a cultural understanding/nonunderstanding of the meaning of a particular instance of self-injury is an important determinant of whether such self-injury is considered pathological/nonpathological. She then shifts the focus to the present-day culture in which women’s bodies are commodified and objectified, and feminism, iconic communication, moral conflict, oppression, psychiatrist/psychologist roles, social norms Potter’s paper considers self-injury in women diagnosed with borderline personality disorder (BPD) to be a form of body modification where the body is used to communicate meaning. She touches on symbolism as a possible explanatory theory for this sort of self-injury. She also refers to the culture of body commodification as underlying self-injury. She then argues that clinicians have a duty to give uptake to the patient’s own interpretations about the meaning of the self-injury. Giving uptake is a virtuous approach for ethical interactions with people diagnosed with BPD who self-injure, and it aims to preserve the communicator’s integrity, along with other benefits. Potter offers five maxims for giving uptake properly. However, I shall argue that giving uptake can be very difficult for clinicians, and that an appreciation of this difficulty depends on an expansion and linkage of some of the theories that she touched on. Self-injury is revisited experimentally as a double-edged sword of symbolic sacrifice and iconic-symbolic self-assertion. This revisiting aims to illustrate how clinicians might be caught in a double bind, where giving uptake properly might be very difficult if not more or less doomed to fail.

Child abuse and the dynamics of silence

In constructively responding to our Viewpoint paper on institutional abuse and societal silence, Haliburn (2014) articulates several core challenges for psychiatry. These are that the mental health consequences of early trauma are too compelling to ignore, that societal silence has a strong tendency to be pervasive, and that we thus have to avoid passively opting for silence if we are to be part of the solution rather than an extension of the problem.